Kurt B. Stevenson

An Antimicrobial Stewardship Program's Impact with Rapid Polymerase Chain Reaction Methicillin-Resistant Staphylococcus aureus/S. aureus Blood Culture Test in Patients with S. aureus Bacteremia

Rapid organism detection of Staphylococcus aureus bacteremia and communication to clinicians expedites antibiotic optimization. We evaluated clinical and economic outcomes of a rapid polymerase chain reaction methicillin‐resistant S. aureus/S. aureus blood culture test (rPCR). This single‐center study compared inpatients with S. aureus bacteremia admitted from 1 September 2008 through 31 December 2008 (pre‐rPCR) and those admitted from 10 March 2009 through 30 June 2009 (post‐rPCR). An infectious diseases pharmacist was contacted with results of the rPCR; effective antibiotics and an infectious diseases consult were recommended. Multivariable regression assessed clinical and economic outcomes of the 156 patients. Mean time to switch from empiric vancomycin to cefazolin or nafcillin in patients with methicillin‐susceptible S. aureus bacteremia was 1.7 days shorter post‐rPCR (P = .002). In the post‐rPCR methicillin‐susceptible and methicillin‐resistant S. aureus groups, the mean length of stay was 6.2 days shorter (P = .07) and the mean hospital costs were

Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial

21,387 less (P = .02). rPCR allows rapid differentiation of S. aureus bacteremia, enabling timely, effective therapy and is associated with decreased length of stay and health care costs.

Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria.

Abstract Objective To assess whether a multifaceted intervention can reduce the number of prescriptions for antimicrobials for suspected urinary tract infections in residents of nursing homes. Design Cluster randomised controlled trial. Setting 24 nursing homes in Ontario, Canada, and Idaho, United States. Participants 12 nursing homes allocated to a multifaceted intervention and 12 allocated to usual care. Outcomes were measured in 4217 residents. Interventions Diagnostic and treatment algorithm for urinary tract infections implemented at the nursing home level using a multifaceted approach—small group interactive sessions for nurses, videotapes, written material, outreach visits, and one on one interviews with physicians. Main outcome measures Number of antimicrobials prescribed for suspected urinary tract infections, total use of antimicrobials, admissions to hospital, and deaths. Results Fewer courses of antimicrobials for suspected urinary tract infections per 1000 resident days were prescribed in the intervention nursing homes than in the usual care homes (1.17 v 1.59 courses; weighted mean difference −0.49, 95% confidence intervals −0.93 to −0.06). Antimicrobials for suspected urinary tract infection represented 28.4% of all courses of drugs prescribed in the intervention nursing homes compared with 38.6% prescribed in the usual care homes (weighted mean difference −9.6%, −16.9% to −2.4%). The difference in total antimicrobial use per 1000 resident days between intervention and usual care groups was not significantly different (3.52 v 3.93; weighted mean difference −0.37, −1.17 to 0.44). No significant difference was found in admissions to hospital or mortality between the study arms. Conclusion A multifaceted intervention using algorithms can reduce the number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes.

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

(See the commentary by Moro, on pages 978-980 .) Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.

SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility

CONTEXT Central line-associated bloodstream infection (BSI) rates, determined by infection preventionists using the Centers for Disease Control and Prevention (CDC) surveillance definitions, are increasingly published to compare the quality of patient care delivered by hospitals. However, such comparisons are valid only if surveillance is performed consistently across institutions. OBJECTIVE To assess institutional variation in performance of traditional central line-associated BSI surveillance. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of 20 intensive care units among 4 medical centers (2004-2007). Unit-specific central line-associated BSI rates were calculated for 12-month periods. Infection preventionists, blinded to study participation, performed routine prospective surveillance using CDC definitions. A computer algorithm reference standard was applied retrospectively using criteria that adapted the same CDC surveillance definitions. MAIN OUTCOME MEASURES Correlation of central line-associated BSI rates as determined by infection preventionist vs the computer algorithm reference standard. Variation in performance was assessed by testing for institution-dependent heterogeneity in a linear regression model. RESULTS Forty-one unit-periods among 20 intensive care units were analyzed, representing 241,518 patient-days and 165,963 central line-days. The median infection preventionist and computer algorithm central line-associated BSI rates were 3.3 (interquartile range [IQR], 2.0-4.5) and 9.0 (IQR, 6.3-11.3) infections per 1000 central line-days, respectively. Overall correlation between computer algorithm and infection preventionist rates was weak (ρ = 0.34), and when stratified by medical center, point estimates for institution-specific correlations ranged widely: medical center A: 0.83; 95% confidence interval (CI), 0.05 to 0.98; P = .04; medical center B: 0.76; 95% CI, 0.32 to 0.93; P = .003; medical center C: 0.50, 95% CI, -0.11 to 0.83; P = .10; and medical center D: 0.10; 95% CI -0.53 to 0.66; P = .77. Regression modeling demonstrated significant heterogeneity among medical centers in the relationship between computer algorithm and expected infection preventionist rates (P < .001). The medical center that had the lowest rate by traditional surveillance (2.4 infections per 1000 central line-days) had the highest rate by computer algorithm (12.6 infections per 1000 central line-days). CONCLUSIONS Institutional variability of infection preventionist rates relative to a computer algorithm reference standard suggests that there is significant variation in the application of standard central line-associated BSI surveillance definitions across medical centers. Variation in central line-associated BSI surveillance practice may complicate interinstitutional comparisons of publicly reported central line-associated BSI rates.

Administrative coding data, compared with CDC/NHSN criteria, are poor indicators of health care–associated infections

Long-term care facilities (LTCFs) may be defined as institutions that provide health care to people who are unable to manage independently in the community.1 This care may be chronic care management or short-term rehabilitative services. The term nursing home is defined as a facility licensed with an organized professional staff and inpatient beds that provides continuous nursing and other services to patients who are not in the acute phase of an illness. There is considerable overlap between the 2 terms. More than 1.5 million residents reside in United States (US) nursing homes. In recent years, the acuity of illness of nursing home residents has increased. LTCF residents have a risk of developing health care-associated infection (HAI) that approaches that seen in acute care hospital patients. A great deal of information has been published concerning infections in the LTCF, and infection control programs are nearly universal in that setting. This position paper reviews the literature on infections and infection control programs in the LTCF. Recommendations are developed for long-term care (LTC) infection control programs based on interpretation of currently available evidence. The recommendations cover the structure and function of the infection control program, including surveillance, isolation precautions, outbreak control, resident care, and employee health. Infection control resources are also presented. Hospital infection control programs are well established in the US. Virtually every hospital has an infection control professional (ICP), and many larger hospitals have a consulting hospital epidemiologist. The Study on the Efficacy of Nosocomial Infection Control (SENIC) documented the effectiveness of a hospital infection control program that applies standard surveillance and control measures.2 The major elements leading to a HAI are the infectious agent, a susceptible host, and a means of transmission. These elements are present in LTCFs as well as in hospitals. It is not surprising, therefore, that almost as many HAIs occur annually in LTCFs as in hospitals in the US.3 The last 2 decades have seen increased recognition of the problem of infections in LTCFs, with subsequent widespread development of LTCF infection control programs and definition of the role of the ICP in LTCFs. An increasingly robust literature is devoted to LTC infection control issues such as the descriptive epidemiology of LTCF infections, the microbiology of LTCF infections, outbreaks, control measures, and isolation. Nevertheless, there is as yet no SENIC-equivalent study documenting the efficacy of infection control in LTCFs, and few controlled studies have analyzed the efficacy or cost-effectiveness of the specific control measures in that setting. Although hospitals and LTCFs both have closed populations of patients requiring nursing care, they are quite different. They differ with regard to payment systems, patient acuity, availability of laboratory and x-ray, and nurse-to-patient ratios. More fundamentally, the focus is different. The acute care facility focus is on providing intensive care to a patient who is generally expected to recover or improve, and high technology is integral to the process. In LTCFs, the patient population may be very heterogeneous. Most LTCFs carry out plans of care that have already been established in acute care or evaluate chronic conditions. The LTCF is functionally the home for the resident, who is usually elderly and in declining health and will often stay for years, hence comfort, dignity, and rights are paramount. It is a low-technology setting. Residents are often transferred between the acute care and the LTC setting, adding an additional dynamic to transmission and acquisition of HAIs. Application of hospital infection control guidelines to the LTCF is often unrealistic in view of the differences noted above and the different infection control resources. Standards and guidelines specific to the LTCF setting are now commonly found. The problem of developing guidelines applicable to all LTCFs is compounded by the varying levels of nursing intensity (eg, skilled nursing facility vs assisted living), LTCF size, and access to physician input and diagnostic testing. This position paper provides basic infection control recommendations that could be widely applied to LTCFs with the expectation of minimizing HAIs in LTC. The efficacy of these measures in the LTCF, in most cases, is not proven by prospective controlled studies but is based on infection control logic, adaptation of hospital experience, LTCF surveys, Centers for Disease Control and Prevention (CDC) and other guidelines containing specific recommendations for LTCFs, and field experience. Every effort will be made to address the unique concerns of LTCFs. Because facilities differ, the infection risk factors specific to the resident population, the nature of the facility, and the resources available should dictate the scope and focus of the infection control program. In a number of instances, specific hospital-oriented guidelines have been published and are referenced (eg, guidelines for prevention of intravascular (IV) device-associated infection). These guidelines are relevant, at least in part, to the LTC setting but may be adapted depending on facility size, resources, resident acuity, local regulations, local infection control issues, etc. Reworking those sources to a form applicable to all LTCFs is beyond the scope of this guideline. Any discussion of infection control issues must be made in the context of the LTCF as a community. The LTCF is a home for residents, a home in which they usually reside for months or years; comfort and infection control principles must both be addressed.

Early experience with tigecycline for ventilator-associated pneumonia and bacteremia caused by multidrug-resistant Acinetobacter baumannii

BACKGROUND ICD-9-CM coding alone has been proposed as a method of surveillance for health care-associated infections (HAIs). The accuracy of this method, however, relative to accepted infection control criteria is not known. METHODS Retrospective analysis of patients at an academic medical center in 2005 who underwent surgical procedures or who were at risk for catheter-associated bloodstream infections or ventilator-associated pneumonia was performed. Patients previously identified with HAIs by Centers for Disease Control and Preventions National Healthcare Safety Network surveillance methods were compared with those of the same risk group identified by secondary infection ICD-9-CM codes. Discordant cases identified by only coding were all rereviewed and adjusted prior to final analysis. When coding and surveillance were both negative, a sample of patients was used to estimate the proportion of false negatives in this group. RESULTS The positive predictive values (PPVs) ranged from 0.14 to 0.51 with an aggregate of 0.23, even after adjustment for additional cases detected on subsequent medical record review. The negative predictive values (NPVs) ranged from 0.91 to 1.00, with an aggregate of 0.96. The estimates of the true variance of PPVs and NPVs across surgical procedures were small (0.0129, standard error, 0.009; 0.000145, standard error, 0.00019, respectively) and could be mostly explained by variation in prevalence of surgical site infections. CONCLUSION Administrative coding alone appears to be a poor tool to be used as an infection control surveillance method. Its proposed use for routine HAI surveillance, public reporting of HAIs, interfacility comparisons, and nonpayment for performance should be seriously questioned.

Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings

Study Objective. To evaluate early experience with tigecycline alone or in combination with other antimicrobials for treatment of ventilator‐associated pneumonia (VAP) and/or bacteremia caused by multidrug‐resistant Acinetobacter baumannii.

Market withdrawal of new molecular entities approved in the United States from 1980 to 2009

Affiliations: 1. Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; 2. Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania; 3. Division of Infectious Diseases, The Ohio State University, Columbus, Ohio. Received July 7, 2011; accepted July 15, 2011; electronically published September 1, 2011. This article is in the public domain, and no copyright is claimed. 0899-823X/2011/3210-0001. DOI: 10.1086/662025 editor’s note

Objective surveillance definitions for ventilator-associated pneumonia.

Economic factors, market dynamics, and safety issues are largely responsible for decisions to withdraw pharmaceutical products from the market. In this study, new molecular entities (NMEs) approved by the Food and Drug Administration (FDA) were examined in the USA from 1980 to 2009.